Provider Demographics
NPI:1033290218
Name:SADDLEBACK VALLEY NEUROSCIENCE MEDICAL GROUP
Entity Type:Organization
Organization Name:SADDLEBACK VALLEY NEUROSCIENCE MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:G
Authorized Official - Last Name:PRESTON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:949-837-1133
Mailing Address - Street 1:23961 CALLE DE LA MAGDALENA
Mailing Address - Street 2:SUITE 317
Mailing Address - City:LAGUNA HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:92653-3616
Mailing Address - Country:US
Mailing Address - Phone:949-837-1133
Mailing Address - Fax:949-830-1154
Practice Address - Street 1:23961 CALLE DE LA MAGDALENA
Practice Address - Street 2:SUITE 317
Practice Address - City:LAGUNA HILLS
Practice Address - State:CA
Practice Address - Zip Code:92653-3616
Practice Address - Country:US
Practice Address - Phone:949-837-1133
Practice Address - Fax:949-830-1154
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-17
Last Update Date:2008-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA=========OtherTAX ID #
CA0614290001Medicare NSC